If you wanted to choose two of the most contentious, most fought-over battlegrounds of the Obama presidency, you couldn’t go far wrong in picking healthcare reform and budgetary spending, with the two issues having on occasion created gridlock and paralysis as well as at times almost bringing the whole US political system to its knees over the past few years. These are linked issues that are unlikely to go away any time soon.
That’s because, of course, sitting over the top of both these short-term political headaches is the longer-term societal pressure of the aging of the US population, the healthcare challenges this is going to pose now and into the future, and how, or who, is going to fund the care of this aging demographic.
An aging population
The number of people in the US aged 65 years or older is expected to double by 2030, according to the Department of Health and Human Services’ Administration of Aging guide for caregivers. In fact, by 2030 there will be 72.1 million ‘older persons’ in the US, more than twice the number there were in 2000, with those aged over 65 accounting for 19% of the population by 2030, compared with 12.4% at the turn of the millennium.
Arguably, one place these two fault-lines are meeting is in access to diagnostic imaging, in particular over plans within the 2013 US budget to shave $820 million off the country’s spiralling healthcare bill by introducing deep cuts to the field.
A coalition of industry bodies – the Access to Medical Imaging Coalition (AMIC), the American College of Radiology (ACR) and the Medical Imaging & Technology Alliance (MITA) – has warned that this could do severe damage to the diagnostic imaging industry. Such cuts, it has argued, could reduce access to diagnostic imaging, with older and more vulnerable patients being especially hard hit. Moreover, it has the potential to be a short-sighted, false economy in terms of likely knock-on increases in healthcare costs because of there being less access to imaging services, not to mention simply being damaging economically to the image-manufacturing sector.
Concern for senior citizens
As Gail Rodriguez, executive director of MITA, argues: "Our biggest concern is for senior citizens. Providers of images have faced eight cuts in the past six years in the fees they receive and there has been a decline in reimbursement amounts.
"Imaging centres have been closing and many areas, particularly rural areas, are now underserved or facing big pressures. There is a lot of consolidation and a lot of pressure on the system. Many research centres have been cut to the bone."
Timothy Trysla, executive director of AMIC, agrees: "Our biggest concern is that recent complex legislative changes to Medicare imaging policies have been driven by Congress’s attempts to find budgetary offsets (for the cost of other federal policies), without regard to the damaging effect that these changes can have on patient access to life-saving care. Diagnostic imaging is one of the key healthcare tools with the potential to cut costs over the long term because of its ability to help with early diagnosis and, perhaps, prevent the need for hospitalisation at a later date."
What’s more, while the 2013 budget has put this issue firmly in the spotlight, it is symptomatic of a longer-term trend of decline, they both argue.
Cuts to imaging reimbursements
Research by MITA, for example, has found that Congress and the US administration have cut imaging reimbursements eight times in six years, with payments for some services being reduced by more than 60%, including payments for bone density screenings, arm and leg artery X-rays, and MRIs of the brain. In fact, imaging spending declined in 2010 to approximately the same level as 2004, MITA said.
A further consequence of the administration’s proposals would be to impose a Medicare prior-authorisation programme for advanced diagnostic imaging services, which in turn could force many suburban and rural imaging providers to limit services to seniors. "The fact our population is aging, and the health needs that go with that, means that we are going to need more imaging services, not fewer," argues Rodriguez. "Obviously it is important within that to have appropriate imaging guidelines for physicians and to stipulate what kind of imaging is appropriate.
"But it should be about using imaging in the right way, not about whether you are able to use or access it at all."
Diagnosis: value for money
Then there is the issue of the ‘false economy’ argument, with a 2009 study by the National Bureau of Economic Research concluding that increased use of imaging is directly related to increased life expectancy and other studies highlighting the value of scanning when it comes to reducing admissions and transfers, and increasing efficiency.
"When you think about it, diagnostic imaging saves so many lives and, in fact, potentially saves so much money through earlier diagnosis and avoiding the need for people to go into hospital for expensive interventions. When was the last time you heard of anyone having exploratory surgery these days?" asks Rodriguez. "Diagnostic imaging has helped immeasurably; for example, with identifying cancers earlier, meaning interventions are able to be made when they are less advanced and more treatable.
"It has also been hugely important in helping physicians to plan their treatments. It can, for example, be very important in helping to determine whether a chemotherapy regime is going well or not. Tracking treatments through diagnostic imaging has had an extraordinary value. So this proposal will damage access and damage use."
"There have been many studies over the years that have shown the reduced admissions that can be the result of effective diagnostic imaging; in some cases CT scans have been shown to reduce admissions for lung cancer by as much as 20%," agrees Trysla.
"There has been increasing recognition of the value of diagnostic imaging in treating some of our most challenging diseases. So what we have been trying to focus Congress on is not just the importance of diagnostic imaging as a medical tool, but also the importance of diagnostic imaging being used in the most appropriate way.
Need to incentivise appropriate imaging
"We want physicians at the point of diagnosis having the best scientific guidelines possible so when they order a test, it is for the best, most appropriate, reasons. So we want them to be using appropriate diagnostic guidelines to make the best decisions. We want physicians to be being advised by best practice guidelines.
"We are concerned about the effect cuts in diagnostic imaging will have on our most vulnerable patients, especially elderly patients. It will be hugely damaging if what we end up with are across-the-board cuts that do not take account of specific needs or problems.
"There is also a need to bring more education into the system, to ensure there is less variance in the ordering of images and more accurate ordering. Physicians need to be working more closely with radiology departments and vice versa."
Anecdotally, he says, there is also more use of older machines because of the reimbursement environment having been so dramatic. These machines are, as a result, less accurate and not as safe.
"Politicians should not be putting in place policies that separate the patient from the doctor," concludes Trysla. "We need systems in place that incentivise quality and appropriate imaging. Rather than integrating systems or reducing access, what we need to be doing is looking at how imaging can be used in the best and most appropriate way to facilitate early diagnosis and reduce intervention."